Preoperative strategies to improve resectability for hepatocellular carcinoma: a systematic review and meta-analysis

Abstract

Preoperative strategies to increase liver volume are effective in achieving resectability of HCC. TACE + PVE is as safe as PVL/PVE providing higher OS. ALPPS is associated with a higher risk of PHLF, major complications, and mortality. RE despite the small experience seems to present similar resection rate and OS as TACE + PVE with higher rate of major complications.

HCC in Cirrhotic and Non-cirrhotic Liver: Timing to Surgery and Outcome - State of the Art

“…Extended resection is feasible when the future remnant liver is ≥40% for cirrhotic patients, ≥30% in patients with severe steatosis or fibrosis without cirrhosis and ≥20% in those with normal liver function [93].…”

“…Several strategies can be carried out in order to increase future remnant liver volume (FRLV), improve resectability and reduce postoperative risk of liver failure (PLF) in patients with inadequate FRLV. These techniques include preoperative portal vein embolization (PVE) or ligation (PVL), sequential transarterial chemoembolization and PVE, two-stage hepatectomy (TSH), preoperative Yttrium-90 ( 90 Y) radioembolization (RE) and associated liver partition and portal vein ligation for staged hepatectomy (ALPPS) [93]. Parenchyma hypertrophy shall be assessed using CT volumetry before performing second-stage hepatectomy [94].…”

“…ALPPS is indicated in non-cirrhotic patients with insufficient remnant liver or in the case of PVE failure [93,95,96]. This procedure allows higher and faster hypertrophy rates compared to other strategies, due to parenchyma transection and collateral portal branches ligation, especially in hepatopathics; such advantages have been seen also in cirrhotic patients [92].…”

“…Postoperative live failure (PLF) is the most life-threatening complication following hepatic resection, especially in cirrhotics [93]. It is defined as the decrease in liver synthetic, excretory and/or detoxifying functions after resection [100].…”

“…It can be associated with insufficient future liver volume, prolonged operative time, prolonged ischemia, massive intra-and postoperative bleeding, hemodynamic instability, bile duct obstruction, drug-induced injury, viral reactivation and sepsis [90]. It occurs after the fifth day in 4-19% of cases, and it is characterized by various symptoms and signs, such as ascites, pleural effusion, prolonged cholestasis, coagulation disorders, elevated serum lactate levels, hyperbilirubinemia, hypoalbuminemia, hypoglycaemia and hepatic encephalopathy [90,93].…”